Treatment options for intrinsic sphincter deficiency.

Type III stress urinary incontinence (SUI) is generally defined as a condition that involves intrinsic sphincter deficiency (ISD). Although the clinical parameters for ISD are loosely defined as a Valsalva leak-point pressure <60 cmH(2)O or a maximal urethral closure pressure <20 cmH(2)O, consensus is lacking. As a result, studies evaluating the success of any treatment for ISD are difficult to interpret. Regardless, several studies over the past 20 years have evaluated a number of surgical and nonsurgical treatments specifically for SUI caused by ISD. Surgical options include retropubic suspension, needle suspensions, various types of suburethral slings and the artificial urinary sphincter, whereas nonsurgical options include urethral bulking agents. Assessing urethral function (specifically, leak-point pressure or maximal urethral closure pressure) and urethral hypermobility will enable treating physicians to determine the ideal solution for individual patients, especially as no standardized treatment for ISD exists.

Carcinosarcoma of the bladder: case report and review of the literature.

Primary osteosarcomas of the bladder account for about 0.04% of bladder neoplasms. Most of the patients in the literature expired within 6 months and, in almost all of the cases in the literature, radical cystectomy with postoperative chemotherapy was the treatment choice. A 79-year-old gentleman presented with gross hematuria. Cystoscopy demonstrated a 2- to 3-cm tumour along the lateral wall of the bladder. The tumour was resected incompletely via initial transurethral resection of bladder tumour (TURBT), and a second TURBT was subsequently performed to fully resect the residual mass. Surgical pathology from these 2 resections revealed osteosarcoma with invasion into the muscularis propria. A cystoprostatectomy was performed and final pathologic specimen revealed high-grade CIS without evidence of residual osteosarcoma. Postoperatively, the patient did not receive chemotherapy or radiation and currently remains disease-free 2 years post-radical cystectomy. Only 33 well-documented cases of primary osteosarcoma of the bladder have been reported to date. However, there are only 3 cases in which TURBT resulted in complete resection.

Spiral sling salvage anti-incontinence surgery in female patients with a nonfunctional urethra: technique and initial results.

PURPOSE: Female patients with severe urethral incompetence are a unique surgical challenge. Urethral closure and continent diversion are often the next step in the treatment of these patients. We present a technique that provides circumferential coaptation of the urethra as a salvage procedure in this severe subset of patients. MATERIALS AND METHODS: We prospectively evaluated 47 patients who had a spiral sling. A 1 x 15 cm piece of soft polypropylene mesh was prepared with a zero polyglactin suture applied at each end. A clamp was used to pass the mesh between the urethra and pubis. The ends of the mesh were crossed at the ventral aspect of the urethra, creating a complete circle around the urethra. The sutures were transferred to the suprapubic area and tied without tension. The surgical outcome was determined by patient self-assessment, including symptom, bother and quality of life questionnaires. RESULTS: Mean patient age was 59 years. At presentation patients had undergone a mean of 2.6 incontinence procedures and wore a mean of 6 pads daily. Mean daily pad use decreased to 0.9 (p <0.005). Preoperatively mean SUI symptom severity and bother scores were 2.8 and 2.9, respectively, on a scale of 0--none to 3--severe. Postoperatively these values decreased to 0.6 and 0.4, respectively (each p <0.005). There was a mean 87% overall improvement in symptoms. CONCLUSIONS: The spiral sling is an effective salvage transvaginal procedure that may be considered in a small subset of female patients with a nonfunctional urethra as a last resort before urethral closure procedures.

Transvaginal paravaginal repair of high-grade cystocele central and lateral defects with concomitant suburethral sling: report of early results, outcomes, and patient satisfaction with a new technique.

Baden-Walker classification grade III-IV (pelvic organ prolapse quantification [POP-Q] system stage III-IV) cystocele is associated with a constellation of abnormalities including urethral hypermobility, lateral defect, central defect, and concomitant vault and posterior wall prolapse. We describe a new transvaginal paravaginal technique to correct this group of abnormalities and report on our early results. We prospectively evaluated patients with high-grade cystocele who underwent repair with the new transvaginal paravaginal repair. Preoperative evaluation included history and physical examination, dynamic pelvic magnetic resonance imaging, urodynamics, and symptom questionnaire. All patients first underwent a distal urethral polypropylene sling surgery. After repair of the central defect of the cystocele, a paravaginal repair of the lateral defect was performed by using a circular 5 cm x 5 cm soft polypropylene mesh attached proximally to the sacrouterine/cardinal ligament, distally to the bladder neck, and laterally to the infralevator obturator fascia. Postoperative evaluation at 3-month intervals included history and physical examination using the POP-Q system, a voiding dysfunction and incontinence symptom questionnaire, the validated short form of the Urogenital Distress Inventory (UDI-6), a validated global quality-of-life question, and a postvoid residual. We performed the repair in 98 patients with a mean age of 65 years (range, 40 to 86 years). Of these, 26% underwent concomitant vaginal hysterectomy, 45% had enterocele repair, and 94% had rectocele repair. There were 2 complications, including transient ureteral obstruction due to bladder wall hematoma and 1 patient who presented with a recurrent enterocele requiring surgical repair. No patient experienced urinary retention. De novo stress urinary incontinence was seen in 3 patients; de novo urge incontinence was seen in 2 patients. Postoperative POP-Q scores showed 85% of patients with stage 0-I, 13% with stage II, and 2% with stage III anterior vaginal wall prolapse. Of patients with preoperative stress urinary incontinence, 70% reported never experiencing symptoms under any circumstances. Quality of life improved from 4.7 to 1 (P < 0.005). Transvaginal paravaginal repair of grade III-IV cystocele using soft polypropylene mesh fixed to the obturator fascia, sacrouterine ligaments, and bladder neck area provides excellent support of the central defect repair as well as repair of the lateral defect. The operation is safe, simple, and outpatient based, and provides excellent anatomic results with minimal complications. Concomitant distal polypropylene sling did not increase the rate of complications and did not compromise results of stress urinary incontinence surgery.

Anterior vaginal wall surgery in elderly patients: outcomes and assessment.

OBJECTIVES: To evaluate the efficacy, safety, and impact on quality of life of anterior vaginal surgery in the elderly. Incontinence in the elderly is a devastating medical and social condition accounting for 50% of admissions to nursing homes; the incidence of anterior vaginal wall prolapse also increases in the elderly. Most patients are treated conservatively, because of a reluctance to offer surgical treatment to this age group owing to the perceived increased risk of complications and decreased rate of treatment success. METHODS: We prospectively evaluated all consecutive elderly patients who underwent anterior vaginal wall surgery between November 1999 and May 2003. The surgical outcomes were determined by the symptom, bother, and quality-of-life questionnaires answered by the patients. The physicians were unaware of the patients' responses. RESULTS: A total of 209 patients were available for analysis. The mean age was 70 years (range 65 to 88) and the mean follow-up 15.3 months. All items in the symptom and bother questionnaires showed significant improvement. Significant improvement was also demonstrated in quality of life and pad use (P <0.005). No significant perioperative complications occurred. Only patients older than 71 years of age did not experience an improvement in the symptom scores for urge incontinence. Nevertheless, as for all other patients, older patients experienced improvement in stress urinary incontinence (SUI) symptoms, the bother scores of SUI and urge incontinence, and quality of life. CONCLUSIONS: Surgical treatment of anterior vaginal wall prolapse and SUI in the elderly is effective and safe and significantly improves the quality of life of these patients.

Impact of vaginal surgery for stress urinary incontinence on female sexual function: is the use of polypropylene mesh detrimental?

OBJECTIVES: To evaluate prospectively the impact of a distal urethral polypropylene sling on sexual function using a validated questionnaire. Suburethral slings are currently the most common anti-incontinence surgery performed. Although the use of polypropylene is safe and effective, concern exists that the presence of the material in the vagina may adversely affect sexual function. METHODS: A total of 29 patients agreed to participate in this prospective study. The patients were evaluated with the Female Sexual Function Index, a validated, 19-item questionnaire that assesses six domains of sexual function: desire, arousal, lubrication, orgasm, satisfaction, and pain. The questionnaires were administered at 6-month intervals during the follow-up visits. RESULTS: The mean patient age was 52 years (range 38 to 72). The mean duration of follow-up was 19.4 months (range 7 to 37). No statistically significant difference was found in sexual function after placement of a distal urethral polypropylene sling. Of the 29 patients, 14% were not sexually active before or after surgery. No statistically significant difference was found between preoperative and postoperative desire, arousal, lubrication, orgasm, satisfaction, and pain. CONCLUSIONS: No change was found in overall sexual function in women undergoing placement of a mid to distal polypropylene urethral sling. Specifically, neither a deleterious effect nor statistically significant improvement was found in sexual desire, arousal, lubrication, orgasm, satisfaction, or pain compared with the preoperative baseline values.

Renal cancer and pregnancy in two different female cohorts.

PURPOSE: Although human renal cell carcinoma (RCC) is considered refractive to hormone therapy, this lesion can be induced in the Syrian hamster by exogenous estrogen. Human RCC also has been demonstrated to contain estrogen receptors. Since there are significant changes of estrogen levels during pregnancy, we wanted to investigate if there were any associations between the hormonal variations of pregnancy and renal cancer in women using two distinct cohorts. MATERIALS AND METHODS: We reviewed the charts of 57 females who presented for treatment of renal cancer. We assessed the size of each tumor radiologically and pathologically, the tumor stage, the number of pregnancies and/or abortions/miscarriages, age at menarche, and use of oral contraceptives. We compared this cohort to a sample of 985 nuns, and then reviewed the literature on the association of pregnancy, contraceptives and renal cell carcinoma. We used analysis of multiple variables (ANOVA) and the student's t test to determine any significance (p<0.05). RESULTS: Our age range was 39 to 67 years, with a mean of 51. The tumor volumes ranged from 9 cm(3) to 1500 cm(3), and the number of pregnancies ranged from 1 to 14. Menarche ranged from 8 to 14. We did not find any significant correlation between menarche or the number of pregnancies and the size or stage of renal cancers. However, our nun population did not reveal any incidence or illness from renal cell carcinoma over a 20 year review. CONCLUSIONS: Although our first cohort did not demonstrate any significant associations between the number of pregnancies or age at menarche and RCC, our second cohort and a review of the literature supports the notion that pregnancy is a risk factor for renal cell carcinoma.